Liaison Psychiatry Flashcards
What is Premenstrual syndrome (PMS)?
Collection of psychological and somatic sx occurring during the luteal phase of menstruation.
How many patients with PMS suffer from severe PMS?
5%
How many women suffer from severe PMS?
3-8%
% of women with severe PMS who have a comorbid mood disorder?
30-70%
What are women with PMDD at higher risk of?
Postnatal depression
Where in ICD is Premenstrual tension syndrome?
Diseases of the Genitourinary tract
Where was PMS classified in DSM IV?
Under depressive disorder not otherwise specific
Where is PMS in DSM V?
As a diagnosis
Which sx of PMS are not seen in depression?
Breast pain
Bloating
At least 1 of which sx must be present for a diagnosis of PMDD for DSM V
Depressed mood
Marked anxiety
Marked affective lability
Marked anger or irritabiity
Duration of sx for diagnosis of PMDD for DSM V
In most menstrual cycles during past year, at least 5 of the 11 sx including one of the first 4 should be present
What are the other sx for PMDD under DSM V aside from the first 4
Anhedonia
Subjective sense of difficulity concentrating
Lethargy
Marked change in appetite or specific food craving
Hypersomnia/insomnia
Subjective sense of being overwhelmed/loss of control
Physical sx
When must sx be present for PMDD diagnosis in DSM V
Must be present most of the time during lat week of luteal phase
Must begin to remit within few days of onset of menstrual flow
Must be absent in the week after menses
Functional criteria for PMDD dx under DSM V
Sx must markedly interfere with work, school, social activities or relationships
Exclusion criteria for PMDD
Sx cannot be an exacerbation of another disorder such as depression
How must criteria be confirmed for PMDD under DSM V?
By prospective daily ratings for at least 2 consecutive menstrual cycles
Pattern for symptoms in PMS
During each cycle, sx last for a few days to up to 2 weeks.
Peak is 2 days before menses.
Hypothesis of pathology underlying PMS
Increased sensitivity to normal fluctuation of gonadal hormones.
How do we know that serotonin has a role in PMS?
Serotonin-enhancing treatments reduce PMS symptoms.
Impairment in serotonin transmission provokes sx.
What does imaging suggest re the pathology of PMS?
May be a role of GABA due to its interaction between progesterone metabolites and GABA-A receptors
Treatment of mild PMS
Lifestyle changes
CBT
Exercise/diet
Treatment for severe PMS
SSRIs
SSRI response rate for PMS
60-90% compared with 30-40% with placebo
Effective medications for PMS
Fluoxetine or Sertraline (best) Citalopram Escitalopram Clomipramine Venlfaxine
Which non-SSRIs can be used for PMS?
Clomipramine
Venlafaxine
Which SSRIs can be used for PMS?
Fluoxetine
Sertraline
Citalopram
Escitalopram
Impact of SSRIs on PMS?
Reduce mood and somatic sx
Improve QoL and social functioning
Most effective drug for PMS
Fluoxetine
What other dosing regime can be used for PMS?
Intermittent dosing during luteal phase; 2 weeks prior to menses.
Odds ratio of SSRI treatment for PMS
6.91 in favour of SSRIs compared with placebo
Difference in sx reduction between continuous and intermittent dosing for PMS?
No difference
Disadvantages of intermittent dosing for PMS?
Lower efficacy for somatic sx
Advantages of intermittent dosing for PMS
More effective than continuous
Cheaper
Less withdrawal due to SEs
When do SSRIs become effective for PMS?
WIthin a few days
Difference in side effects if SSRIs used for depression vs. PMS
In PMS lower frequency of sexual side effects and no reports of akathisia or increased suicidal ideation
Which other medications can be used (with caution) in PMS?
Alprazolam in premenstrual insomnia and anxiety
Hormonal treatment
How does hormonal treatment work in PMS?
Suppresses ovulation
Which hormonal treatments can be used for PMS?
Long-acting GnRH agonist, oestrogen
When should hormonal treatment be considered for PMS?
Only as last resort
Possible consequences of hormonal treatment for PMS
Introducing early menopause
Remission rates of PMS
Low on cessation of treatment
How many patients with coronary heart disease have comorbid depression?
20%
What type of interventions can reduce depression in patients with coronary artery disease?
Psychological & behavioural
Risk of patients with persistent depression who also have coronary artery disease?
Increased cardiac risk
Studies in patients with coronary artery disease and depression
Enhancing Recovery in Coronary Heart Disease (ENRICHD) for CBT
Myocardial Infarction and Depression Intervention Trial (MIND-IT)
Canadian Cardiac Randomization Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) for interpersonal therapy
COPES - problem-solving therapy trial
Women’s Heart Study - CBT based stress management
What do ENRICHD and MIND-IT show?
CBT only has modest effects on depression and neither improve survival.
What is the largest randomised trial evaluating use of antidepressants on depressed patients with heart disease?
Sertraline Antidepressant Heart Attack Randomized Trial (SADHART)
Structure of SADHART
Compared Sertraline v placebo in 16 week trial
Results of SADHART
No difference in safety (LVEF, premature ventricular contractions, QTc prolongation)
Nonsignificant reduction in endpoint (MI or CHD death) in Sertraline group
What did SADHART show re impact of Sertraline on depression?
Little difference in depression status after 24 weeks treatment
Effect of Sertraline greater in patients with severe and recurrent depression
Prevalence of depression in CCF patients
21.5% (2-3 times higher than general population)
What is higher prevalence of depression in CCF associated with?
Females
Higher NYHA functional class
Relative risk of mortality in patients with CCF who are depressed
2:1 compared to risk in non-depressed CCF patients
What does severe depression in CCF increase rates of?
Clinical events
Rehospitalisation
General health care use
Psychiatric sx in hyperthyroidism
Generalised anxiety Depression Irritability Hypomania Cognitive dysfunction Mania in severe thyrotoxicosis
M:F ratio of hypothyroidism
1:6
Psychiatric sx of hypothyroidism
Depression
Cognitive dysfunction
Psychosis in severe cases
What is subclinical hypothyroidism a risk factor for?
Depression
Rapid cycling in Bipolar
Sx at mild-moderate (10-14) hyperparathyroidism?
Depression
Apathy
Irritability
Lack of initiative
Sx at severe (>14) hyperparathyroidism
Delirious with psychosis
Catatonia
Lethargy progressing to coma
Sx in mild hypoparathyroidism
Anxiety
Paresthaesias
Irritability
Emotional Lability
Sx in severe hypoparathyroidism
Mania
Psychosis
Tetany
Seizures
Most common cause of Cushings Syndrome
Exogenous steroids
What causes Cushings disease?
ACH secretion from pituitary tumour
Corticosteroid secretion from adrenal adenoma
Physical sx of Cushings syndrome
Diabetes Hypertension Muscle weakness Obesity Osteopenia
Psychiatric sx of Cushings syndrome
Depression (most common) Anxiety Hypomania/mania Psychosis Cognitive dysfunction
Which type of steroid is more likely to produce mania?
Exogeneous
Psychiatric sx of Addisons
Apathy Anhedonia Fatigue Depression Anorexia
Which sx are present in Addisons but not in depression?
Nausea, vomiting
Skin changes 0 dark pigmentation
What causes Acromegaly?
Excess growth hormone
Psychiatric sx of Acromegaly
Mood lability
Personality change
Depression
How can Acromegaly cause psychosis?
With treatment of Bromocriptine - dopamine agonist
Cause of Phaechromocytoma?
Catecholamine-secreting tumour
Physical sx of Phaechromocytoma>
Tachycardia
Labile hypertension
Headache/sweating
Episodic palpitations
How is Pheochromoctyoma screened?
Urinary catecholamines - Vanillyl mandelic acid, metanephrines
Best diagnostic test for Pheochromoctyoma?
Plasma metanephrine level
Rates of depression in patients with Diabetes
2-3 times more common compared to general population
Correlation between Depression and Diabetes
Poorer glycaemic control
Increased diabetic complication
Which psychiatric disorders have increased prevalence of TII DM?
Bipolar
Schizophrenia (2-4 times higher)
Severe depression
How can Diabetes lead to cognitive dysfunction?
Frequent hyperglycaemic episodes result in cerebral micro and macrovascular damage
Prevalence of depression in those with advanced cancer
5-15%
Which sx are not useful in diagnosing depression in those with advanced cancer?
Somatic sx
What is a useful criterion for depression in those with advanced cancer?
Pervasive global anhedonia
Drug treatments for depression in palliative care
SSRI
Low dose Amitriptyline
Lofepramine
Rapid-acting psychostimulants e.g. Dexamphetamine/methylphenidate
When should Amitriptyline be avoided in palliative care?
High risk of delirium
When is Amitriptyline helpful in palliative care?
Neuropathic pain
Prevalence of delirium in cancer in-patients?
44%
Prevalence of delirium in patients shortly before death
62%
Impact of diazepam use in end stage renal disease?
The metabolite desmethyldiazepam may accumulate, causing excessive sediation
Impact of Lorazepam in end stage renal disease
Half life increased from 8-25 hours to 32-65 hours.
By how much should lorazepam dose be reduced in low level of renal function?
By 50%
Which antidepressants can be used at normal dose in renal impairment?
Imipramine
Amitriptyline
Fluoxetine
Fluvoxamine
Which antidepressant should not be used in renal impairment?
Sertraline
Which medications should be reduced in renal impairment and the elderly?
Half dose of Citalopram
Reduced dose in Paroxetine
Which antipsychotic should be avoided in renal impairment?
Amisulpride
Which antipsychotic does not require dose reduction in renal impairment?
Haloperidol - unless excessive sedation or hypotension occur
Dosing of Amisulpride in renal failure if no other option
Alternate day dosing or dose reduction
Impact of Risperidone in renal impairment
Active metabolite 9-hydroxy-risperidone is excreted in urine so eliminatino half life is prolonged
When does uraemic encephalopathy occur?
When eGFR falls to 10% of normal
Sx of uraemic encephalopathy
Cognitive dysfunction Psychomotor activity Change in personality Vomiting Restlessness Myoclonus Coma
What is dialysis disequilibrium syndrome?
Temporary clinical disorder that may occur during first few days of dialysis.
Who is dialysis disequilibrium syndrome more common in?
Younger patients
Pre-existing neurological problems
Sx of dialysis disequilibrium syndrome?
Headache Restlessness Nausea/vomiting HTN Tremor Disorientation Seizures
What are most of the sx of dialysis disequilibrium syndrome a result of?
Cerebral Oedema
What causes Lyme disease?
Borrelia burgdorgeri transmitted via wooden tick bite which lives on deers.
Signs of Lyme disease
Red spot develops around location, and develop a central clearing called erythema migrans within 4 weeks.
How many patients with erythema migrans develop neuroborreliases?
15%
What is neuoborreliases?
Lyme disease where CNS is affected
Sx of Lyme disease
Back pain worse at night
Facial numbness
Facial palsy
Where is Lyme disease common?
North America
Sx of late-stage Lyme disease
Memory impairment Word-finding problems Visual/spatial processing impairment Slowed processing of information Psychosis Seizures Violent behaviour
Psychiatric sx of SLE
Depression
Anxiety
Psychosis (Rare)
Physical sx of SLE
Chronic, remitting-relapsing course of febrile illness, butterfly rash, inflammation of joints, kidney and serosa
In which patients with SLE is butterfly rash common?
Middle-aged women
What characterises SLE?
Anti-nuclear antibodies
CNS manifestations of SLE
Peripheral neuropathy Grand mal seizures Chorea and choreoathetosis Cognitive impairment Severe headaches Stroke B Cell Lymphoma Limbic-encephalitis type picture
Sx of Insulinoma
Recurrent headache
Lethargy
Diplopia/blurred vision - with exercise/fasting
Psychosis/depression
What is Neurosarcoidosis?
Idiopathic granulomas in various tissue - mainly lungs and mediastinal node.
May affect CNS - mainly CN.
Sx of neurosarcoidosis
Bilateral facial palsy
Depression - 20%
Psychosis
Erythema nodosium
Blood test results in Neurosarcoidosis
Raised ACE levels due to macrophage activity
Treatment of Neurosarcoidosis
Immunosuppression
What happens in Metachromatic Leucodystrophy (MLD)?
Impairment of development of myelin sheath.
Cause of MLD
Genetic defecs of enzyme arylsulfatase A.
Forms of MLD
Late infantile
Juvenile
Adult
What is the most common form of MLD?
Late infantile
Signs of late infantile MLD?
Children have difficulting walking after first year of life Muscle wasting/weakness Muscle rigidity Developmental delays Progressive loss of vision leading to blindness Convulsions Impaired swallowing Paralysis Dementia
Outcome of late infantile MLD
Most children die by age of 5
Onset of juvenile MLD
3-10 years of age
Sx of juvenile MLD
Impaired school performance
Mental deterioration
Dementia
Slower progression of sx of late infantile MLD
When does adult form of MLD begin?
> 16 years of age
Sx of adult form of MLD
Progressive dementia or psychiatric disorder
Mental deterioration
Depression
How many patients with adolscent-onset MLD have schizophrenia-like psychosis?
60%
What is Neuroacanthocytosis?
Genetically heterogenous neurologic disorder characterised with acanthocytosis.
Sx of Neuroacanthocytosis?
Movement disorders/ataxia Personality changes Cognitive deterioration Axonal neuropathy Seizures -tonic-clonic Subcortial dementia
What is acanthocytosis?
10-30% of patients erythrocytes having a star-like appearance with projections.
Gait of those with neuroacanthocytosis?
Lurching with long strides
Quick, involunary knee flexion
Age of onset of MS
20-40
Lifetime risk of MS in the UK
1:8000
Gender disparity in MS
Twice as common in women
Geographical distribution of MS
Greater frequency as distance from equator increases
Pathology of MS
Multiple demyelinating lesions with predilection for optic nerves, cerebellum, brainstem and spinal cord.
How many people with MS have a steady progression of disability with no remission?
5-10%
How many patients with MS have a relapsing-remitting course?
20-30%
How many patients with MS have a progressive deterioration following a number of relapses and remissions?
60%
Treatment for MS
Steroids
Glatiramer acetate
How does Glatiramer acetate work for MS?
Neuroprotective
Immunomodulator
When is Glatiramer acetate used in MS?
Reduces frequency of relapses in relapsing-remitting MS
Trade name of Clatiramer acetate?
Copaxone
Dose of Glatiramer acetate?
20mg OD s/c
Lifetime prevalence of depressive sx in MS
40-50% - 3x higher than general population
What is depression in MS linked with?
Poorer cognitive function
Poor compliance with treatment
Lower QoL
What can cause drug-induced low mood in MS?
Steroids
Baclofen
Dantrolene
Tizanidine
Brain abnormalities between MS and depression?
None
Treatment used for depression in MS?
Desipramine
SSRI
ECT
Risk of ECT use in MS
20% risk of triggering relapse of MS
What must be done before ECT is used for depression in MS?
MRI to look for presence of active brain lesions - risk factor for MS relapse
Suicide rates of people with MS
3% over 6 year period
15% over 16 years
Drug-induced mania causes in MS
Steroids
Baclofen
Dantrolene
Tizanidine
What is Tizanidine?
Central muscle relaxant
How many patients with MS on steroids develop mild to moderate mania?
33%
Which patients with MS on steroids are more likely to develop hypomania?
FHx of affective disorder/alcoholism
Premorbid history of affective disorder/alcoholism
Link between Psychosis and MS
Patients with psychosis and mania who have MS have plaques distributed in bilateral temporal horn areas
Psychiatric sx of MS
Depression Psychosis Mania Pathological laughing and crying syndrome/pseudobulbar affect Cognitive Impairment
Treatment for pathological crying/laughing in MS
75mg Amitroptyline OD Amantadine Levodopa Fluoxetine Sertraline Citalopram
Impact of Amitriptyline on pathological crying/laughing in MS?
66% of patients had improvement in sx
What type of cognitive impairment is seen in MS?
Subcortical pattern
Is MMSE useful to identify cognitive impairment in MS?
No
Treatment for cognitive impairment in MS?
Donepezil
Prevalence of post-stroke depression?
35%
Which type of stroke has higher incidence of depression?
Subcortial
Infarcts of basal ganglia - especially left hemisphere.
What type of stroke has high incidence of anxiety?
Cortical
Prevalence of post-stroke anxiety?
25%
Prevalence of apathy without depression in stroke?
20%
Prevalence of emotional incontinence in stroke?
20%
Prevalence of catastrophic reaction in stroke?
20%
Mean duration of post-stroke depression?
34 weeks
Screening guidelines for depression and anxiety in stroke
Screen in first month after stroke.
Confirm emotionalism by simple questions.
If one mood disorder is present, assess for others
Treatment for mild-moderate post-stroke depression
Increase social interaction
Exercise
Psychosocial intervention
Treatment for severe post-stroke depression
Antidepressants
Monitor effectiveness
How long should antidepressants be used for post-stroke depression if good initial effect
At least 4 months
Which antidepressants have good evidence for post-stroke depression?
Fluoxetine
Citalopram
Frequency of depression in epilepsy
30-50%
Frequency of panic disorder in epilepsy
20%
Frequency of psychosis in epilepsy
3-7%
Which type of epilepsy is depression most common in?
TLE
Risk of suicide in patients with epilepsy
10-15%
Mortality rate if epilepsy and depressed
25x higher than general population
First line treatment of depression in epilepsy
SSRIs - may reduce seizure threshold
Which type of epilepsy is psychosis more common in
Partial epilepsies
Risk factors of psychosis in epilepsy
Role of mesial temporal and extratemporal damage
When is episodic psychosis most common in epilepsy?
Post-ictal
What is more common in post-ictal psychosis than in functional psychosis?
Visual hallucinations
Which psychotropic can cause psychosis?
Vigabatrin
Which antipsychotics are less epileptogenic?
Sulpride
Haloperidol
What are pseudoseizures linked with?
Past psychiatric hx
Somatisation
Social stressors
Childhood abuse
Prolactin levels in seizures
Increased after epileptic seizures but should be taken within 15 mins of seizure
Prevalence of depression in Parkinsons
40-50%
Prevalence of hypomania/euphoria in Parkinsons
2%/10%
Prevalence of anxiety in Parkinsons
50-65%
Prevalence of Psychosis in Parkinsons
40% - drug-related
Prevalence of cognitive impairment in Parkinsons
19% if no dementia
25-40% if dementia
